My father is 81 years old and is a prostate cancer survivor. He had his prostate surgically removed about 18 years ago (when he was 63). It was an early stage cancer, so thankfully no chemotherapy or radiation was ever necessary.

Unfortunately, his PSA was never at “zero” following the surgery. It started out around 0.5 and it has been steadily climbing over the years (usually one or two tenths each year, etc.). However, in the past 12 months, it has jumped from 3.8 to 5.0, and his internist has recommended that he schedule an appointment with his oncologist.

The only problem is that he does not want to follow-up with his oncologist. He keeps saying things like “they can’t really do anything about it” or other remarks such as “don’t worry, at my age, something else will probably get me”. Is he right? Is there something he can do?

He is otherwise a fairly healthy person for someone his age. Good physical shape. Never smoked or drank. The only real meds he takes are for high blood pressure. He walks, plays the violin, and surfs the internet everyday!
Any suggestions are welcome. I will show him this posting at the right time.

Your dad is actually doing quite well, though there is a potential threat, and there is a lot that could be done, some of which he would probably find quite acceptable. I'll insert some comments in green.

At age 81, he might be right about something else getting him, but, especially because he is in good health, it would be better to halt or slow that PSA rise before it builds up momentum.

A lot of us are excited about the research on quality pomegranate juice or pomegranate extract pills for supporting prostate cancer treatment, including use in slowing or halting recurrence. While the FDA recently cautioned POM Wonderful about some overblown claims, there is actually some highly promising research behind the idea that pomegranate can slow or halt a recurrence. The key study was done by a crack UCLA nutrition oriented research group who looked at PSA doubling time (PSADT)for men who were recurring after surgery for prostate cancer. At enrollment in the trial, their PSA doubling times averaged 15 months - not super fast, but fast enough to cause concern long term. After two years on eight ounces of the juice daily, their PSADTs increased to over 50 months (51 months per my unaided recollection)! A followup of men who stayed on the research protocol showed their doubling time averaged 88 months! Independent confirmatory trials have been underway, and we should have results soon. In the meantime, a patient can see how he responds on his own without waiting for the trial results. I prefer the pills because they have no sugar. I can do without the calories and sugar in the drink.

Other lifestyle tactics are also looking good, though there is no conclusive evidence. Vitamin D3, in a quality supplement that actually helps raise the 25-hydroxy vitamin D level per a simple blood test, looks promising. Other dietary tactics and exercise appear to be helpful.

The mild drugs finasteride (now available as a replacement for brand name Proscar) or Avodart, both in the 5-alpha reductase inhibitor class, have proven activity against prostate cancer. These mild hormonal therapy drugs - taken as pills - may be all that a patient with a mild recurrence needs.

Statin drugs, especially when taken for three years or more, really cut the lethality of prostate cancer.

If a patient wants to do more, a moderate strength form of hormonal therapy involving the now generic drug bicalutamide may do the trick. It often involves some breast issues when used alone, but it is otherwise not burdensome. A few patients have liver issues on the drug, so a liver function test is done until it is clear the patient tolerates it well.

Another option, more demanding, is a course of stronger hormonal therapy for about a year. The combo I favor involves an LHRH agonist drug (such as Lupron, Zoladex - going generic very soon, Trelstar, Viadur, etc.) plus an antiandrogen (usually bicalutamide), and either finasteride or Avodart.

The bottom line: there's a range of options, most of them not very burdensome.

Take care,

Jim

He is otherwise a fairly healthy person for someone his age. Good physical shape. Never smoked or drank. The only real meds he takes are for high blood pressure. He walks, plays the violin, and surfs the internet everyday!
Any suggestions are welcome. I will show him this posting at the right time.

Dad finally went to his oncologist (last year) and has been taking Proscar for about 12 months. Unfortunately, the PSA rise hasn't really slowed down much. As previously stated, it was 5.0 in October 2010, then 11.6 in November 2011, and now 16.0 in May 2012.

In addition to the Finasteride, the oncologist is now recommending 50mg of Casadex per day, which Dad doesn’t want to take because of the possible side effects. And despite the rising PSA, he feels very good. No pain anywhere. He’s 83 now and still cuts the grass and does yard work!

Is Casadex really that bad? I personally think the advantages will outweigh the disadvantages, but he was hoping to hear from a few people who have actually taken it for a while, etc.

I am impressed with your father’s long 20 years history as a PCa survivor.
The length may be the reason for your dad’s refusal in an aggressive form of treatment, but the doubling in PSA is indicative of metastases, probably at bones, which will cause discomfort and nasty pain. This is not what he wants to experience in his “longevity” healthy status at the 80th. You could try to make him aware of the symptoms he surely will confront and suggest the benefits of some sort of control in the advancement of the cancer.

Hormonal treatments are not a walk in the park. There are risks and side effects to mitigate. The results, however, differ among the patients, and in some guys the symptoms are mild. Changing the life style is usually one way to counter the effects.
No one knows for sure if in fact hormonal treatment has a good effect in your father’s case without trying it firstly. If not hormonal then he can only recur to forms of chemo treatments or immunological therapies. Chemo seems to be worse in the sense of nasty symptoms.

By saying that, I would recommend him to follow his oncologist suggestion in starting the Casodex. He can always abstain from the drug if he feels uncomfortable with the symptoms (similar to menopause) or if any indication arises from cardio/heart problems or diabetes. He also should get a bone density scan to check for bone health. Overall he will need to constantly monitor the lipids (anemia in particular), PSA and Testosterone levels.

Hope he accepts your advice.
Wishing you both peace of mind.

Baptista

Last edited by Baptista; 05-29-2012 at 06:47 AM.

The Following User Says Thank You to Baptista For This Useful Post:Phillip F (05-31-2012)

I'm responding to your post #4, but I have read Baptista's response and your post #6.

I have been on "Casodex" for three long periods, including parts of the second and third period when I was using the generic version (much less expensive) "bicalutamide". That's why I mentioned bicalutamide earlier; it's a common approach in situations like your father's where a much milder form of hormonal therapy may do all that is needed. I was on the drug for 28 months during my first "on therapy" cycle of intermittent blockade, on it again for 19 months for the second cycle, and again for 19 months for the third cycle. Each time I used it in combination with Lupron, and almost all of the time with either Avodart (briefly) or Proscar (or its generic version, finasteride).

My experience is somewhat different from what Baptista described, especially in the absence of menopause-like symptoms: no hot flashes, especially, no mood swings. One of the attractive features of this drug is avoidance of the bothersome symptoms of drugs like Lupron, Zoladex, Viadur, and Trelstar, the LHRH-agonist group. Casodex at 50 mg (my dose throughout) is generaly considered a fairly mild drug.

The one most notable likely side effect is some breast enlargement and possible tenderness or even pain there. That usually is very mild or does not happen when the drug is used in combination with an LHRH-agonist, but it is quite common when the drug is not used in that combination. Apparently simple surgery can remove the excess breast tissue, or a short course of radiation before starting can prevent the buildup. (Some doctors are concerned that that might increase the likelihood of breast cancer years later, but your dad may be old enough that that would not matter even if it were a real risk, given enough time.)

There is an unlikely but potentially serious side effect in some patients, depending on genes: liver damage. That's why patients are monitored monthly with a liver function test until it is clear that the liver handles the drug with ease. If a problem occurs, the drug is stopped early, and the liver recovers with no lasting effect. It is possible to use a drug like ursodiol up front or if damage occurs, which may enable the patient to continue to use Casodex/bicalutamide despite the problem.

I like the idea of monitoring PSA and DHT while on the drugs. Cardiovascular health tends not to be much affected by these drugs, unlike the impact of the LHRH-agonist drugs, where lipid monitoring is important, as I understand it.

Your dad also might want to consider switching from finasteride to Avodart, which is somewhat more effective for many of us, though not effective, because of our genes, in a very few. Casodex/bicalutamide and finasteride or Avodart are often used in combination. One leading medical oncologist put it this way about effectiveness: this combination is roughly 80% as effective as full blockade that also includes the LHRH-agonist, but has roughly 20% of the side-effect burden. In short, the patient is drastically reducing the side-effect burden. Learning that should make your dad more comfortable with the approach.

About your dad's PSA rise, I'm thinking that something really slowed down the rate of increase, perhaps finasteride. The PSA appeared to be doubling in about a month in 2011, though based on just two tests, but is apparently rising at a fast but much slower rate now. Still, more is needed than just the finasteride. Bicalutamide could be all that is needed, with lifestyle tactics helping in support.

Bone metastases are likely downstream if nothing is done, the threat Baptista posted about. Fortunately, my impression of research is that no bone mets are likely at present; the current PSA increase is probably due to a recurrence of long-dormant cells in the prostate bed where it was removed or in lymph nodes in the general region of the prostate.

Take care,

Jim

Last edited by IADT3since2000; 06-05-2012 at 06:00 AM.
Reason: Changed second "Lupron" to "Avodart (briefly) in second paragraph.

The Following User Says Thank You to IADT3since2000 For This Useful Post:Phillip F (06-04-2012)